Spinal deformity and paraplegia/quadriplegia are the most common complications of tuberculosis (TB) of spine. TB of dorsal spine almost always produces kyphosis while cervical and lumbar spine shows reversal of lordosis to begin with followed by kyphosis. kyphosis continues to increase in adults when patients are treated nonoperatively or by surgical decompression. In children, kyphosis continues to increase even after healing of the tubercular disease. The residual, healed kyphosis on a long follow-up produces painful costopelvic impingement, reduced vital capacity and eventually respiratory complications; spinal canal stenosis proximal to the kyphosis and paraplegia with healed disease, thus affecting the quality and span of life. These complications can be avoided by early diagnosis of tubercular spine lesion to heal with minimal or no kyphosis. When tubercular lesion reports with kyphosis of more than 50° or is likely to progress further, they should be undertaken for kyphus correction. The sequential steps of kyphosis correction include anterior decompression and corpectomy, posterior column shortening, posterior instrumentation, anterior bone grafting and posterior fusion. During the procedure, the spinal cord should be kept under vision so that it should not elongate. Internal kyphectomy (gibbectomy) is a preferred treatment for late onset paraplegia with severe healed kyphosis.

Degenerative disease of the lumbar spine is common in ageing populations. It causes disturbing back pain, radicular symptoms and lowers the quality of life. We will focus our discussion on the surgical options of posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF) and minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) for lumbar degenerative spinal deformities, which include symptomatic spondylolisthesis and degenerative scoliosis. Through a description of each procedure, we hope to illustrate the potential benefits of TLIF over PLIF. In a retrospective study of 53 ALIF/PLIF patients and 111 TLIF patients we found reduced risk of vessel and nerve injury in TLIF patients due to less exposure of these structures, shortened operative time and reduced intra-operative bleeding. These advantages could be translated to shortened hospital stay, faster recovery period and earlier return to work. The disadvantages of TLIF such as incomplete intervertebral disc and vertebral end-plate removal and potential occult injury to exiting nerve root when under experienced hands are rare. Hence TLIF remains the mainstay of treatment in degenerative deformities of the lumbar spine. However, TLIF being a unilateral transforaminal approach, is unable to decompress the opposite nerve root. This may require contralateral laminotomy, which is a fairly simple procedure.The use of minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) to treat degenerative lumbar spinal deformity is still in its early stages. Although the initial results appear promising, it remains a difficult operative procedure to master with a steep learning curve. In a recent study comparing 29 MI-TLIF patients and 29 open TLIF, MI-TLIF was associated with longer operative time, less blood loss, shorter hospital stay, with no difference in SF-36 scores at six months and two years. Whether it can replace traditional TLIF as the surgery of choice for degenerative lumbar deformity remains unknown and more studies are required to validate the safety and efficiency.

Development and treatment of spinal deformity in patients with cerebral palsyAthanasios I TsirikosApril-June 2010, 44(2):148-158DOI:10.4103/0019-5413.62052 PMID:20419001

Scoliosis is a common deformity in children and adolescents with cerebral palsy. This is usually associated with pelvic obliquity due to extension of the curve to the sacrum. Sagittal plane deformity is less common and often develops along with scoliosis. Spinal deformity in patients with severe neurological handicaps can affect their ability to sit and cause significant back pain or pain due to rib impingement against the elevated side of the pelvis on the concavity of the curvature. Surgical correction followed by spinal arthrodesis is indicated in patients with progressive deformities which interfere with their level of function and quality of life. Spinal deformity correction is a major task in children with multiple medical co-morbidities and can be associated with a high risk of complications including death. A well-coordinated multidisciplinary approach is required in the assessment and treatment of this group of patients with the aim to minimize the complication rate and secure a satisfactory surgical outcome. Good knowledge of the surgical and instrumentation techniques, as well as the principles of management is needed to achieve optimum correction of the deformity and balancing of the spine and pelvis. Spinal fusion has a well-documented positive impact even in children with quadriplegia or total body involvement and is the only surgical procedure which has such a high satisfaction rate among parents and caregivers.

Background: Four-corner fusion of the wrist is an option for management of non-union scaphoid with painful arthritis of the wrist. Various surgical techniques have been devised for four-corner fusion, with inconsistent results. We present our experience of four-corner fusion achieved using a standard H-plate, designed originally for anterior cervical plating.
Materials and Methods: The study is a retrospective analysis of six cases of painful wrist arthritis resulting from nonunion of scaphoid treated by four-corner fusion, between 1996 and 2004. The average duration of follow-up was 5.8 years. Each patient was evaluated clinically according to the rating scales described by Bach.
Results: The mean grip-strength calculated as a percentage of the uninvolved side was 47% pre-operatively, and 74% post-operatively at the final follow-up. The difference between the preoperative and postoperative 'pain ratings' and 'activity ratings' was found to be statistically significant (P<0.001). Mean time to fusion was 16.1 weeks. Dorsal impingement was the most common associated problem.
Conclusions: H-plate, used for four-corner fusion, provides rigid fixation, ensures fusion, and is a good alternative to the available options.

Background: The manipulation and corrective cast application for club foot was known to be done by Kite's method. The Kite's method of manipulation (center of rotation of malaligned foot and fulcrum on cuboid) was modified by Ponseti (fulcrum on head of talus). Recently, Ponseti's method has gained popularity and vastly improved results are reported. We report randomized controlled trial where manipulation of club foot was done by Ponseti's and Kite's method and correction evaluated by Pirani score to compare the outcome of treatment.
Materials and Methods: Sixty feet in 38 patients, 22 with bilateral and 16 with unilateral clubfeet in children less than two years of age and without any prior manipulation or surgical treatment were randomly allocated to the Ponseti (30 feet) and Kite (30 feet) methods of manipulation. This process resulted in the right and left feet of the same patient in 12 bilateral cases being compared with one another (Paired analysis). In the remaining 10 bilateral cases, four patients had both feet treated by Ponseti and six had both feet treated by Kite (unpaired analysis). Finally, in 16 unilateral cases, 10 feet were allocated to the Ponseti and six to Kite methods of manipulation (unpaired analysis). Feet were followed up weekly for 10 weeks for change of cast and recording of hindfoot, midfoot and total Pirani scores. Correction was measured as a difference between hindfoot, mid foot and total Pirani scores weekly from weeks 1 to 10 and corresponding baseline scores. Absolute correction and rate of correction in (i) bilateral clubfeet treated by Ponseti's method on one side and Kite's method on the other side in the same patient were compared using paired Student's t test and (ii) patients with unilateral clubfoot (where either of the methods was used) or those with bilateral clubfoot (where both feet treated by either of the two methods on both the sides) were compared using difference between means (mean correction by Ponseti minus mean correction by Kite) for magnitude of difference and unpaired Student's t test (if data was normally distributed) or Mann Whitney U statistics (otherwise) for significance of difference.
Results: In 12 bilateral clubfeet, where one foot received Kite's method and the other Ponseti's manipulation, feet treated by Ponseti's technique showed faster rates of decrease in Pirani score (improvement) as compared to feet treated by Kite's method with the mean of difference between baseline and follow up scores showing significantly greater (P<0.05) difference from zero from fourth week onwards to up to 10 weeks. In unpaired analysis, both for unilateral or bilateral clubfeet, regardless of side, mean Pirani scores in Ponseti feet improved much faster than Kite feet but the difference achieved statistical significance only at the 10 th week from the start of treatment.
Conclusions: Hind foot, midfoot and total Pirani scores reduce much faster with Ponseti than the Kite's method of manipulation of clubfoot. In paired analysis the difference becomes statistically significant at fourth week and in unpaired analysis at 10 th week from the start of treatment.

Background: Various modalities of treatment from standard discectomy, microdiscectomy, percutaneous discectomy, and transforaminal endoscopic discectomy have been in use for lumbar intervertebral disc prolapse. The access to spine is kept to a minimum without stripping paraspinal muscles minimizing muscle damage by posterior interlaminar endoscopic approach. The aim of this study was to evaluate technical problems, complications, and overall initial results of microendoscopic discectomy.
Materials and Methods: First 100 consecutive cases aged 19-65 years operated by microendoscopic dissectomy between August 2002 - December 2005 are reported. All patients with single nerve root lesions including sequestrated or migrated and selected central disc at L4-5 and L5-S1 were included. The patients with bilateral radiculopathy were excluded. All patients had preoperative MRI and first 11 patients had postoperative MRI to check the adequacy of decompression. Diagnostic selective nerve root blocks were done in selective cases to isolate the single root lesion when MRI was inconclusive (n=7). All patients were operated by a single surgeon with the Metrx system (Medtronics). 97 were operated by 18-mm ports, and only three patients were operated by 16-mm ports. Postoperatively, all patients were mobilized as soon as the pain subsided and discharged within 24-48 h postsurgery. Patients were evaluated for technical problems, complications, and overall results by modified Macnab criteria. Patients were followed up at 2, 6, and 12 weeks.
Results: The mean follow up was 12 months (range 3 months - 4 years). Open conversion was required in one patient with suspected root damage. Peroperatively single facet removal was done in 5 initial cases. Minor dural punctures occurred in seven cases and root damage in one case. The average surgical time was 70 min (range 25-210 min). Average blood loss was 20-30 ml. Technical difficulties encountered in initial 25 cases were insertion of guide pin, image orientation, peroperative dissection and bleeding problems, and reaching wrong levels suggestive of a definitive learning curve. Postoperative MRI (n=11) showed complete decompression. Overall 91% of patients had good-to-excellent results, with four patients having recurrence of whom three were reoperated. Four patients had postoperative discitis. One of the patients required fusion for discitis and rest were managed conservatively. One patient had root damage to L5 root that had paresthesia in L5 region even on 4 years of follow-up.
Conclusion: Microendoscopic discectomy is minimally invasive procedure for discectomy with early encouraging results. Once definite learning curve was over and expertise is acquired, the results of this procedure are acceptable safe and effective.

Congenital spinal vertebral anomalies can present as scoliosis or kyphosis or both. The worldwide prevalence of the vertebral anomalies is 0.5-1 per 1000 live births. Vertebral anomalies can range from hemi vertebrae (HV) which may be single or multiple, vertebral bar with or without HV, block vertebrae, wedge shaped or butterfly vertebrae. Seventy per cent of congenital vertebral anomalies result in progressive deformities. The risk factors for progression include: type of defect, site of defect (junctional regions) and patient's age at the time of diagnosis. The key to success in managing these spinal deformities is early diagnosis and anticipation of progression. One must intervene surgically to halt the progression of deformity and prevent further complications associated with progressive deformity. Planning for surgery includes a preoperative MRI scan to rule out spinal anomalies such as diastematomyelia. The goals of surgical treatment for congenital spinal deformity are to achieve a straight growing spine, a normal standing sagittal profile, and a short fusion segment. The options of surgery include in situ fusion, convex hemi epiphysiodesis and hemi vertebra excision. These basic surgical procedures can be combined with curve correction, instrumentation and short segment fusion. Most surgeons prefer posterior (only) surgery for uncomplicated HV excision and short segment fusion. These surgical procedures can be performed through posterior, anterior or combined approaches. The advocates of combined approaches suggest greater deformity correction possibilities with reduced incidence of pseudoarthrosis and minimize crankshaft phenomenon. We recommend posterior surgery for curves involving only an element of kyphosis or modest deformity, whereas combined anterior and posterior approach is indicated for large or lordotic deformities. In the last decade, the use of growing rods and vertebral expandable prosthetic titanium rib has improved the armamentarium of the spinal surgeon in dealing with certain difficult congenital spinal deformities. The goal of growing rod treatment is to provide simultaneous deformity correction and allow for continued spinal growth. Once maximal spinal growth has been achieved, definitive fusion and instrumentation is performed.

Melioidosis, an infection due to gram negative Burkholderia pseudomallei, is an important cause of sepsis in east Asia especially Thailand and northern Australia. It usually causes abscesses in lung, liver, spleen, skeletal muscle and parotids especially in patients with diabetes, chronic renal failure and thalassemia. Musculoskeletal melioidosis is not common in India even though sporadic cases have been reported mostly involving soft tissues. During a two-year-period, we had five patients with musculoskeletal melioidosis. All patients presented with multifocal osteomyelitis, recurrent osteomyelitis or septic arthritis. One patient died early because of septicemia and multi-organ failure. All patients were diagnosed on the basis of positive pus culture. All patients were treated by surgical debridement followed by a combination of antibiotics; (ceftazidime, amoxy-clavulanic acid, co-trimoxazole and doxycycline) for six months except for one who died due to fulminant septicemia. All other patients recovered completely with no recurrences. With increasing awareness and better diagnostic facilities, probably musculoskeletal melioidosis will be increasingly diagnosed in future.

Use of vacuum assisted closure in instrumented spinal deformities for children with postoperative deep infectionsFederico Canavese, Joseph I KrajbichApril-June 2010, 44(2):177-183DOI:10.4103/0019-5413.62067 PMID:20419005

Background: Postoperative deep infections are relatively common in children with instrumented spinal deformities, whose healing potential is somewhat compromised. Children with underlying diagnosis of cerebral palsy, spina bifida and other chronic debilitating conditions are particularly susceptible. Vacuum-assisted closure (VAC) is a newer technique to promote healing of wounds resistant to treatment by established methods. This article aims to review the efficacy of the VAC system in the treatment of deep spinal infections following spinal instrumentation and fusion in children and adolescents.
Materials and Methods: We reviewed 33 patients with deep postoperative surgical site infection treated with wound VAC technique. We reviewed clinical and laboratory data, including the ability to retain the spinal hardware, loss of correction and recurrent infections.
Results : All patients successfully completed their wound VAC treatment regime. None had significant loss of correction and one had persistent infection requiring partial hardware removal. The laboratory indices normalized in all but three patients.
Conclusions: Wound VAC technique is a useful tool in the armamentarium of the spinal surgeon dealing with patients susceptible to wound infections, especially those with neuromuscular diseases. It allows for retention of the instrumentation and maintenance of the spinal correction. It is reliable and easy to use.

Medial clavicle fractures are the least common type of clavicular fractures. Although rare, such injuries deserve rapid diagnosis and effective treatment to avoid future complications. An optimal, standardized operative treatment has not been yet established. We report a case of medial clavicle fracture, where primary operative treatment was indicated due to gross dislocation. An open reduction and osteosynthesis with a modified hook plate was performed, leading to an excellent postoperative outcome after a sixteen-month follow-up. The hook plate seems to be a promising approach for the operative treatment of medial clavicle fractures.

Background : Pedicle screw instrumentation of the deformed cervical and thoracic spine is challenging to even the most experienced surgeon and associated with increased incidence of screw misplacement. Iso-C3D based navigation has been reported to improve the accuracy of pedicle screw placement, however, there are very few studies assessing its efficacy in the presence of deformity. We conducted a study to evaluate the accuracy of Iso-C3D based navigation in pedicle screw fixation in the deformed cervical and thoracic spine.
Materials and Methods : We inserted 98 cervical pedicle screws (18 patients) and 242 thoracic pedicle screws (17 patients) using Iso-C3D based navigation for deformities of spine due to scoliosis, ankylosing spondylitis, post traumatic and degenerative disorders. Two independent observers determined and graded the accuracy of screw placement from postoperative computed tomography (CT) scans.
Results : Postoperative CT scans of the cervical spine showed 90.8% perfectly placed screws with 7 (7%) grade I pedicle breaches, 2 (2%) grade II pedicle breaches and one anterior cortex penetration (< 2mm). Five lateral pedicle breaches violated the vertebral artery foramen and three medial pedicle breaches penetrated the spinal canal; however, no patient had any neurovascular complications. In the thoracic spine there were 92.2% perfectly placed screws with only six (2%) grade II pedicle breaches, eight (3%) grade I pedicle breaches and five screws (2%) penetrating the anterior or lateral cortex. No neuro-vascular complications were encountered.
Conclusion : Iso-C3D based navigation improves the accuracy of pedicle screw placement in deformities of the cervical and thoracic spine. The low incidence of pedicle breach implies increased safety for the patient.

Background: Congenital constriction band is the most common cause of terminal congenital malformation of a limb and lymphoedema. Superficial bands do not need any treatment, but deeper bands are managed with excision and Z-plasty. The circumferential bands are released in two to three stages to prevent vascular compromise. The purpose of this study was to present the outcome of one-stage release.
Materials and Methods: Nineteen children, 12 boys and 7 girls, with 24 congenital constriction bands constituted the clinical material. The mean age at presentation was 57 days (range 12 hours to 3 years) Band was unilateral in 14 and bilateral in five limbs. In unilateral cases, right side was involved in nine cases and left side in five. The constriction band is seen at the junction of middle and distal third. The patients having constriction bands in lower limbs and age less than 3 years were included in the study. One stage circumferential release of congenital constriction band was performed. Our youngest patient was operated at the age of six months. Club feet, (n=8) and lymphedema (n=7) were associated anomalies. Club feet and band were released in one stage in three limbs. The results were evaluated by criteria described by Joseph Upton and Cissy Tan.
Results: There were 18 excellent, six satisfactory results. No wound problem occurred. No vascular compromise was noted during or after the procedure. On follow-up, distal swelling reduced.
Conclusion: One-stage circumferential release of congenital constriction band in lower limbs with or without lymphodema is a safe and easy procedure.

Background: The key to the safe and effective use of thoracic pedicle screws in the deformed spine is to thoroughly understand pedicle anatomy. There are a few studies related to pedicle anatomy in the Indian population and no pedicle morphometric studies in scoliosis patients. The present study aims to highlight the differential features of pedicle morphometry, including pedicle width, transverse pedicle angle and the depth to anterior cortex on the concave and convex side, in a group of Indian patients with adolescent idiopathic scoliosis and compare this to that of a western population.
Materials and Methods: This is a prospective study of 24 patients with adolescent idiopathic scoliosis. The average age is 14.6 years (12.3-18.3 years) of which 14 were females and 10 were males. All the patients underwent CT scan using Siemens 4 th generation scanner. The scans were analyzed by measuring the transverse pedicle width, transverse pedicle angle and the chord length; all the measurements being made both on the convex as well as the concave pedicle. Statistical analysis was performed with unpaired 't' test.
Results: A total of 1295 measurements were performed from 24 patients and an average of 215 pedicles were assessed for each set of the measurements made. The transverse pedicle width was consistently found to be smaller on concave side in comparison with the convex side at all levels except at T1. The transverse pedicle angle was greater on the concave side at all levels as compared to the convex side, though there was wide individual variation. The depth to anterior cortex was lesser on convex side in comparison to the concave side except at T1.
Conclusions: The concave pedicle is much thinner and directed more medially than the convex side, especially at the apical region of the scoliotic curve. The pedicle anatomy in scoliosis patients shows very high individual variations and a careful study of pre-operative CT scans is essential for planning proper pedicle screw placement. Slightly longer screws can be accommodated on the concave side as compared to the convex side, though the difference in the chord length is not statistically significant at most levels.

Absence of the palmaris longus tendon in Indian populationPawan AgarwalApril-June 2010, 44(2):212-215DOI:10.4103/0019-5413.61863 PMID:20419011

Background: Ethnic variations in the prevalence of the absence of the palmaris longus (PL) tendon are well known. Studies have also attempted to correlate its absence with other anatomical anomalies. However, most studies have been done in Caucasian populations. The present study was undertaken to know the occurrence of absence of palmaris longus in Indian population.
Materials and Methods: The presence of the PL tendon was clinically determined in 385 normal Indian men and women using the standard technique. In subjects with an absent PL tendon, three other tests were performed to confirm its absence. All subjects were also examined for the presence of the flexor digitorum superficialis (FDS) in the little finger.
Results: The overall unilateral absence of the tendon was 16.9% and the bilateral absence was in 3.3% in our population. There was no significant difference in its absence with regard to the body side or sex. The overall prevalence of the weak FDS in the little finger irrespective of the presence or absence of the PL tendon in our study was 16.10%. If we compare the deficiency of the FDS in the little finger with the absence of the PL tendon, the overall incidence is 4.15% and is statistically significant, while the sexwise distribution of the weak FDS with absent PL tendon was statistically significant in males and in females it was statistically insignificant.
Conclusions: The prevalence of the unilateral absence of the PL tendon in an Indian population is comparable to the western population but a bilateral absence is significantly less. In patients with an absent PL tendon, the FDS of the little finger is weak, especially in males.

Background: Multiple osteoporotic vertebral compression fractures (VCFs) have been treated with polymethylmethacrylate augmentation; however, there are cement complications and long-term fracture healing that are unknown. Transpedicle body augmenter (a porous titanium spacer) has been reported as an internal support to reconstruct the vertebral body combining short-segment fixation in burst fracture and Kümmell's disease with cord compression. Transpedicle body augmenter for vertebral augmentation (TpBA) also has been reported successfully in treating single painful VCF and vertebral metastasis lesions including pending fractures and pathologic compression fractures. To test the hypothesis that TpBA can effectively and safely treat the symptomatic multiple VCFs, this retrospective study was done by analyzing the radiographic and clinical results.
Materials and Methods: We retrospectively reviewed clinical and radiographic results of TpBA for symptomatic multiple (more than two levels) VCFs in 62 patients with a total of 236 levels, i.e. 3.8 VCFs per patient. Manual reduction and TpBA via paramedian incisions with blunt dissection were done. One incision was made for two continuous levels and alternative side was selected for next incision. Mean age was 74.3 years (range, 62-87 years), and female-male ratio was 5.2:1. Anterior vertebral height and wedge angle by radiographic findings were measured at preoperative, initial follow-up and final follow-up. Clinical results were assessed by questionnaires and clinical observations. By July 2008, 58 patients returned to answer the questionnaire including quantification of pain on the visual analog scale, the response to operations (better, same, or worse after operation), returned to their pre-fracture function (yes/no) and satisfaction (a scale of 0 = completely dissatisfied to 10 = completely satisfied).
Results: The mean symptom duration was 7 months, and follow-up, 48 months. The average operation time was 21 min per level, blood loss was 74 cc per level and hospitalization was 4.4 days. No patient had neurological deterioration. There was no dislodgement of implant in the final visit. Forty-eight patients (77.4%) could walk within 6-8 h after operation and the others, within 24 h. The anterior vertebral restoration was 7.3 mm initially and 6.2 mm at final follow-up. Wedge angle correction was 10.4° initially and was 9.3° at final follow-up. Pain, by the visual analog scale, was 8.5 preoperatively, 2.7 at day 7 follow-up and 2.9 at final follow-up. By the questionnaire, 52 of 58 respondents reported a decrease in discomfort after TpBA and 48 of 58 patients reported a return to normal activity after operation. The final satisfaction rate was 89.7%.
Discussion: The symptoms of multiple osteoporotic compression fracture may be due to unstable fracture, radiculopathy, and global traumatic kyphosis with posture changes, which can be corrected by multiple TpBA. The transpedicle body augmenter was initially stabilized by the sinking and locking mechanism and finally by bone ingrowth.
Conclusions: TpBA via a minimally invasive method led to early and medium-term clinical improvements and anatomic restoration of multiple symptomatic VCFs.

A 40-year-old man sustained trauma while walking and presented three months after trauma. The attitude of left hip was flexion, neutral rotation, and neutral abduction/adduction with an arc of flexion available from 30° to 90°. No movement was possible in other planes. On roentgenogram and 3D computed tomography, the femoral head was lying inferior and medial to the acetabulum, and it was in the same coronal plane of the acetabulum, neither anterior nor posterior, within the pelvic cavity. An indentation over the superolateral half of femoral head was observed. The acetabulum was found intact except for a small defect in the inferior aspect of its medial wall. Cemented total hip replacement was done without any need to reconstruct the acetabulum, and at the two years follow-up, the patient was having a pain-free, stable hip and was able to walk unaided. We hereby report a late presentation of intrapelvic dislocation of hip in view of rarity.

We present a case of simultaneous dorsal perilunate dislocation of both wrists, without a history of fall on outstretched hands. In contrast, it appeared that the mechanism was reverse. His hands were held in radial deviation with wrists in full palmar flexion. The forearms were in neutral position and elbows in mid-flexion. The wrists were suddenly and forcibly pronated. The radiographs of both wrists showed dorsal perilunate dislocation with avulsion fracture of the tip of ulnar styloid process and avulsion fracture of posterior horn of lunate. Radial translation of the carpal bones was also noted. The mechanism is proposed and discussed.

Bifid first metacarpal is a common congenital anomaly. Here, we report an unusual case of bifid first metacarpal in a 13-year-old girl who presented with swan neck deformity of left thumb, a bony prominence on ulnar aspect of left thumb in the first web space and a bifid first metacarpal lacking its own epiphysis. The patient underwent surgery, resulting in complete functional recovery as well as cosmetic improvement of the left thumb.